Methotrexate (Parenteral) (Metoject/Nordimet pens; Zlatal syringes) -Subcutaneous use in inflammatory bowel disease, psoriasis; rheumatoid arthritis; connective tissue disease

SCAMethotrexate_PPMO_Immuno_01032026.pdf

NICE recommendations, summary of meeting discussions, links to additional supporting docs etc.

Dose errors have caused fatalities. Norfolk shared-care guidelines should be followed to protect staff and patients from this cytotoxic drug. Robust method of communicating dosage alterations is fundamental to patient safety.

Guidelines and a shared care protocol for use of methotrexate in the community were reviewed by TAG in May 2004 and are broadly supported. Education and training of primary care staff in administration of injectable methotrexate is provided NNUH Rheumatology Department.

NPSA documentation on safe management of patients on methotrexate is also available.

February 2009: The TAG noted NICE Clinical Guideline 79 – Rheumatoid Arthritis

January 2012: The TAG noted and supported a revised NNUHFT guideline on administration of subcutaneous methotrexate which reflected current use of Metoject® locally.

January 2013: Indications for Shared Care revised to include Connective Tissue Disease and Felty’s Syndrome. Revised Shared Care Agreement supported by the TAG and the D&TCG.

July 2015: Shared Care Agreement reviewed. Clarification that the specialist has responsibility for the first blood test. Also updated in line with current format.

July 2016:

The TAG was advised that revised Arthritis Research UK advice, states that men no longer need to stop taking methotrexate before trying to conceive.

The TAG noted the information provided and agreed that the local shared care agreement should be updated in line with this guidance.

Available via: http://nww.knowledgeanglia.nhs.uk/tag/tag_guidance.htm

September 2017:  The local Shared Care Agreement was updated following the publication of the revised BSR and BHPR guidelines for the prescription and monitoring of non-biologic disease-modifying drugs 2017.

March 2018: The TAG agreed revisions to the text regarding specifiying use in Crohn’s disease rather than IBD; the need to ensure continuity in injection devices; removal of discontinued pre-filled syringe Methofill; responsibility for dosage changes specified to be of the specialist (not the GP); frequency of recommended monitoring to be specified in the letter to GPs.

May 2018: The TAG supported the addition of a statement supporting GPs to provide varicella vaccination to the very small number of patients who are identified by the specialist service as being non-immune to varicella (chickenpox) prior to them starting treatment with methotrexate.

May 2018: Supported by the D&TC.

September 2018:

The TAG noted NICE NG 100 (July 2018) – Management of rheumatoid arthritis in adults, which included new and updated recommendations on:

*           investigations following diagnosis

* treat-to-target strategy and initial pharmacological management

* symptom control and monitoring

and also:

* investigations for diagnosis and referral from primary care

* non-pharmacological management and the multidisciplinary team

* communication and education

September 2018:

NICE NG 100 (July 2018) was noted by the N&W CCGs’ Drugs & Therapeutics Committee

September 2018:

The TAG noted and a revised Specialist Treatment Pathway for Rheumatoid Arthritis which had been updated with the most recent advice on adalimumab. The place of baricitinib was also clarified.

The TAG was advised that (biosimilar) adalimumab (once available) would remain as the CCGs’ preferred 1st line (biologic) treatment option; a JAK inhibitor would be considered only where biologics are contraindicated.

Any further comments from the Trusts regarding the order of use of NICE-recommended therapies within the pathway to be submitted to the CSU’s Specialist Interface Pharmacist.

The TAG otherwise agreed with the treatment pathway in principle.

September 2018:

The N&W Drugs & Therapeutics Committee (D&TC) noted and supported the TAG’s recommendations